Chapter 1: Evidence-based Healthcare

Evidence-based Healthcare (EBHC):

Current best evidence is up-to-date information to look at the effects of
different forms of health care, the harm from treatment, the accuracy of
diagnostic tests and the prognostic factor
- Evidence-based {Public Health, Medicine, Physical Therapy, Nutrition,
Nursing , so on….}

Clinic decisions are based on experience with a population of patients rather

than on personal or other experience of doc or other health care workers.

Evidence-based medicine (EBM):

Is a systematic approach to the acquisition, appraisal, and application of
research evidence to guide decisions in healthcare.

Why do we need EBM?

Major concerns are that
1- clinical decision bases on personal experience NOT current valid scientific
evidence
2- Information sources as books do not often provide current valid scientific
evidence to make clinical decisions
Example:

Summary:
If you require evidence based real time information, you should not consult
textbooks
What are the skills of EBM ?
Acquiring the evidence
Appraising the evidence
Applying the evidence

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1. Step 1: Acquiring the evidence

Determine the type of question to select the best source of information

1.1: Ask a focused clinical question (what is the problem?)

We use PICO framework to design a research questions to ask database.

P à Patient or Problem or Population I à Intervention or exposure
What are the patient’s characteristics (age, What main intervention is being considered
gender) with the problem? (medication or exercises)?
C* à Comparison or Control (placebo) O à outcome
What is the main alternative comparison What is the desired effect being
treatment(s) being considered? considered? And What are the side effects?
* Comparison is not always present in a PICO analysis

There are five type of questions: {Therapy, Prevention, Diagnosis, Prognosis and Etiology}

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Examples:
In adults with depression, Is Duloxetine (DE) more effective than Therapy
Escitalopram (EM)in relieving depressive symptoms?
In hypertensive patients, does the use of Calcium channel blockers prevention
(CCBs) as compared to angiotensin-converting enzyme (ACE) reduce
the risk of progression to end-stage renal disease?
In stroke patients, is CT scan more accurate than 2D-Doppler Diagnosis
unltrasound for diagnosis of carotid artery disease?
In low-back pain (LBP) patients, Treated with opioids with in the first prognosis
two week of LBP onset what is the probability of work disability at 3
months?
Among college students, by how much does smartphone addiction etiology
(SPA) Increases the risk of dry eye disease?

1.2: Searching the medical literature

à PICO framework is the gateway to medical literature, why?

è Databases don’t understand questions or sentences
è Databases classify articles according to separated PICO elements
è Databases obtain information by processing the PICO elements connected
together by Boolean operators (AND, OR, NOT)

§ Point 1:
Are obesity people an increased risk of mortality from covid-19 as compared to non-obesity people?
à P (concept1) àO (concept3) à I (concept2)
Extract Key Concepts
an abstract idea, which can usually be presented in more than one way with words &
phrases in the text of articles E.g. Smartphone and students.

§ Point2:

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§ Point3:
Medical Subject Headings (MeSH) to obtain Controlled vocabulary and Keywords

Controlled vocabulary: a standardized representation of concepts in bibliographic databases

E.g. the controlled vocab for mobile phone in PubMed is cell phone.
Example1:

Concept 1 Concept 2 Concept 3

indicate MeSH term

§ Point4: Boolean operator

Why this point is important? to select all possible papers.

Concept 3

Concept 2

Concept 1

39K

1.3M 1.6M

1.3: Retrieving the medical literature and get copy

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2. Appraising the evidence

(Do we have to read all 164 articles ? This step is to assess the evidence by reading abstract.)
2.1: Appraising directness
à Directness: How well the PICO in the article corresponds to the PICO of your clinical
question.

2.2: Appraising validity

à Validity: Will we believe it ?
1) Internal validity: the study was designed and it is free from bias (accurate results)
- Bias: systematic deviation of the findings from the truth, which leads to under-
estimation or over-estimation of the outcome measure.
2) External validity: the results of the study are applicable to your patient or
population (generalizability).

2.3: Appraising the results Does it work?

1- 𝐄𝐟𝐟𝐞𝐜𝐭 𝐬𝐢𝐳𝐞: is magnitude of effect of intervention (exposure) on the outcome of interest
Ex: smoking (smoker) and heart attack

2- which measure is it used to present the relationship?

Mean difference, relative risk reduction, absolute risk reduction, sensitivity, specificity, likelihood
ratio, odds ratio, hazard ratio, etc.

3- The aim is to decide if the observed effect is clinically relevant

E.g.: Drug A reduce the weight 5 kg /3 months and Drug B reduce the weight .5 kg/3months
Drug A is clinically relevant.

Scientific articles may simply be untrue , why?

• small 𝐞𝐟𝐟𝐞𝐜𝐭 𝐬𝐢𝐳𝐞
• tiny clinically relevant
• invalid measure analyses
• conflicts of interest

3. applying the evidence

3.1 Assessing applicability:
- the results of a study can be expected to hold true for a particular patient
- Consider the biologic & socio-economic differences

3.2 Individualization (the results how will affect my patient):

• Studies report the average effects of interventions at group level
• We deal with individual patients whose responses may not be average
• The effect is based on patient

3.3 Sharing the decision

- Help the patient understand the quality of the evidence
- Respect patient/population values
- Assess performance of the patients

Evidence does not abolish your clinical judgement, evidence is just a guide
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Classification system for EBHC resources

1) Hierarchy of evidence in primary studies
Systematic review is a study deign has strongest evidences.

Your goal is to identify

the strongest source of
evidence to answer your
focused clinical question

2) Level of processing of the evidence

a) Primary studies
Disadvantage:[complex & time consuming, huge data(20M papers are published
annually)]

b) Systematic reviews (why have strongest evidence?)

a study type that assesses the results of all studies addressing a research question &
provides a summary estimate of effects across studies. It includes quality of
methodology of included studies and Meta-analysis (statistical technique that
combines the results of several studies in a single weighted estimate of effect size)

c) Clinical guidelines
statements that include recommendations, intended to optimize patient care, that
are informed by a systematic review of evidence and an assessment of the benefits
and harms of alternative care options.

Epidemiology
The study of the occurrence, states, and processes in specified populations, including the
study of the determinants influencing such processes, and the application of this knowledge
to control relevant health problems.

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Study designs ( Epidemiology)

Clinical Epidemiology
“The application of epidemiological knowledge, reasoning, and methods to study clinical
issues and improve clinical care”

Biostatistics
Refers to the application of statistical principles & methods to test research
questions in healthcare

Epidemiology (research designs) & biostatistics (statistical tests) provide

information (research evidence) to inform clinical decisions (EBHC)

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